Name: Referred by:

Date of intake assessment: Date of referral:

Psychologist: Supervisor:
Notes:  Referral Reason
 History
- Onset
- Recent events
 Previous
diagnosis/treatment
 Family psyc history
 Medical history
- Gen pract.
- Medications
 Neurovegetative Signs
- Sleep
- Weight
- Appetite
- Energy
- Motivation
- Mood
- Libido
- Short term
memory
 Genogram
 Relationships including
family
 Parental history
 Occupation, education,
income
 Suicide assessment
- Risks
- Protective fac.
- Did you have
any self-harm
thoughts?
 Risk level
 Developmental
history/major
milestones
 Genetic issues
 Drug/alcohol use
 Strengths and
resources
 Mental State Exam
- Appearance
- Behaviour
- Relationship
with examiner
- Affect and
mood
- Thought
processes
- Thought
content
- Perceptual
disturbances
- Insight and
judgement